According to a new CDC report, only 1 in 3 doctors advise their adult patients to exercise. The survey-based findings are limited, in part, because they rely on people’s recollection of whether they’d visited a physician in the previous year and what they were told. Nonetheless, the study revealed some clear trends:

1. In 2010, 32.4% of adults who’d seen a health care professional were advised to begin or continue with exercise or other physical activity. That fraction’s up significantly from 2000, when a slim 22.6% of patients recalled their doctors telling them to get a move on.

2. Among folks over 85 years, nearly 29% say they were told to exercise. That number’s nearly doubled since 2000, when only 15.3% of elderly patients reportedly received this kind of advice.

3. Adults with diabetes were told to increase their activity more often than those with high blood pressure, cardiovascular disease and cancer. Compared with healthy weight adults, obese people were twice as likely to have been told to exercise by a physician or other health professional.

An underlying message is that doctors should be prodding their patients to exercise. From the report:

Research points to the benefits of physical activity for reducing the risk of chronic health conditions (1–4). Engaging in regular physical activity can reduce medication dependence, help maintain functional independence, and improve the quality of life for older adults (5,6). Physicians and other health professionals can be influential sources of health information, and exercise counseling by primary care physicians has been shown to increase patients’ participation in physical activity (6–9).

There was discussion about this yesterday on Twitter, stemming in part from a USA Today article on the report. And here’s the essence of the short-form debate:

Some suggested that doctors don’t tell patients to exercise because they, themselves, are overweight. Or it’s because they don’t feel comfortable recommending for others what they don’t do themselves. While this might explain some physicians’ behavior or discomfort with the topic, it can’t explain that of the majority.

So why don’t more doctors prescribe exercise for their patients?

Reasons I wonder about include a lack of time for “non-essential” communication, especially in clinics. In specialists’ offices, the omission of exercise could have to do with the visit’s purpose. A gastroenterologist or internist who evaluates a patient for a problem like diarrhea, say, might not think to ask about exercise. For some doctors it might be, problematically, an attitude issue – that they just don’t care that much, or think it would be a waste of time to discuss the matter of exercise.

Whatever the reasons are that most doctors don’t bring up the issue, one might ask this: Why do adults need doctors to tell them about the health benefits of regular exercise? After all, it’s common knowledge – the kind of thing taught in elementary school, like nutrition should be – that regular exercise is good for most people. As we age, being out of condition makes every task in life, like walking a few blocks, harder.

In an ideal world, we’d have most adults exercising regularly, and doctors who’d occasionally intervene and counsel patients about what they shouldn’t do because of a particular medical condition, like arthritis or heart limitation. I guess we’re not there yet –

Yesterday morning, two women who were active in the on-line breast cancer community died.

Rachel Cheetham Moro (1970 – 2012) was a critical thinker who vigorously supported BCAction and the NBCC’s 2020 deadline. She was a generous and thoughtful on-line friend to many women in the metastatic and more general BC community, where she used the handle @ccchronicles. Her blog provided a running, witty commentary on breast cancer news and trends. Interspersed, she detailed occasional and lately, more frequent visits to the hospital, a Florida vacation, and reflections on her earlier years. In a recent post, she included this wonderful high school photo.

high school photo, from the Cancer Culture Chronicles

Dr. Susan Niebur was a mother in her late 30s, an astrophysicist and blogger who generously shared her experiences at her Toddler Planet blog and elsewhere, including on Twitter as @whymommy. She dealt with inflammatory breast cancer starting in April, 2007. In recent months she wrote less frequently, but positively somehow, while taking radiation treatments for painful bone mets, going in and out of the hospital and, most recently, receiving hospice care at home.

Susan Niebur in 2011, Toddler Planet

Each of these women inspired many people I know. They were brave and open, and helped others to understand what it’s like to face progressive, metastatic disease. Their words didn’t only affect people with breast cancer, but influenced also their loved ones, and individuals who face all sorts of limiting illness.

Yesterday’s Times offered two distinct perspectives on weight loss. One, a detailed feature on gastric surgery by Anemona Hartocollis, details the plight of a young obese woman who opts for Lap-band surgery. In this procedure, surgeons wrap a constricting band of silicone around the stomach so that patients will feel full upon eating less food than they might otherwise. Allergan, the company that manufactures the device, admits to these complications on its website.

The other, a discussion of resolutions and will-power by John Tierney, considers strategies for sticking to diets, exercise regimens and other good intentions for the new year. Within this piece lies a distracting story of an obese (375 pound) hedge fund manager whose gastric band failed to keep his appetite in check. When he landed a project in Las Vegas and feared regaining weight, he aimed high – to lose 100 pounds, outfitted his hotel suite with a gym, and hired a personal trainer to stay nearby and keep him on track in terms of meals and exercise. This costly “outsourcing” of will-power is, obviously, not an option for most people.

Tierney does offer some reasonable suggestions – like setting realistic goals, weighing yourself daily, Tweeting your weight, logging into a weight-loss website, not freaking out if you blow your diet one day, etc.

But here’s the thing – how do doctors fit into this picture? In the last few years that I was practicing hematology, I saw a few patients who had B12 deficiency after gastric bypass surgery. These patients turned out to have multiple problems after their stomachs were cut so they’d eat less food. For some it was helpful; I saw individuals who lost over 150 pounds. Still, the surgery was huge and risky. I can’t fathom having recommended it to a patient whom I cared for, unless perhaps I’d personally witnessed her struggling to lose weight for over, say, 8-10 years.

Because most people, if inspired or starved, can lose weight. This may sound cruel, but what if the doctors recommending the procedure don’t have sufficient confidence in their patients?

The Lap-band is sold as a safer alternative, but upon reading the story (an anecdote, but telling), you have to wonder what are patients’ expectations of the procedure, and how well do they understand the likely risks and benefits. Who are the doctors who tell them about the procedures, and what are their ties with industry (besides the obvious link of surgeons who do the surgery and recommend it).

Like patients with cancer, patients with obesity may feel desperate. But unlike cancer, obesity is almost always a function of choices we make, and for which I think we have to hold people responsible.

Doctors, maybe, should expect more of their patients. “Yes, you can lose 30 pounds over the next 2 years,” one might say. And they might talk about strategies, Tierney-style or otherwise, based on the patient’s preferences and personality. “Come into my office once each month for a weigh-in” might be very effective in persuading patients to shed pounds. A technician could do the monthly measurement in the office or medical home, and the doctor or nurse might follow-up with an encouraging email. Imagine that!

So why don’t more general practitioners, including pediatricians, offer this sort of weight-loss approach? Is it too simple a strategy that doctors don’t find it interesting? Or not sufficiently profitable for the office or medical center?

The author is saddened to learn that Christopher Hitchens died late yesterday evening at the age of 62, roughly a year and a half after receiving a diagnosis of esophageal cancer. He was a prolific and articulate man; I respected him for his words.

His essays on the language and cancer might be of particular interest to some readers of this blog.

The NCI reports there are some 17,000 new cases of esophageal cancer in North American each year; it’s not a common tumor, and most cases arise in men. The annual number of deaths from esophageal cancer approaches 15,000 in the U.S. These numbers are telling: it’s not an easy disease to have, or to treat.

Is a question I ask myself almost every day. When I started this blog, it was partly a response to what I perceived an unbalanced attack on the value of breast cancer screening by the mainstream news outlets. Why it’s continued is, mainly, that I find it liberating and, in a strange way, fun. As I’m no longer practicing, this wide-open world of shared facts, some questionable, and new ideas keeps me alert and, maybe, in-touch.

But if that’s what doctors’ blogs are about, why don’t we just call it PR?

As I’ve said before, I do see value in academics blogging, especially if they’re not afraid to question, and don’t simply kiss up to authors who’ve published articles in major journals. I can see how Twitter from a trusted source like the CDC could be a rapid way to disseminate information about a new viral strain, an urgent need for blood donors, or a real public health emergency.

But for most practicing physicians, I just don’t see how they have time for it. Unless it’s like a hobby, or better – an open notebook – a way of recording your thoughts on what you’ve seen and learned in the day. That kind of blog can be great, even useful, for patients and other docs. The main thing is that the purpose of physicians’ and hospitals’ websites or blogs should be clear.

Recently I saw a tweet by @jamierauscher about whether she thinks to inform her docs about her use of social media. That’s a separate topic.

Over the weekend I developed another bout of diverticulitis. Did the usual: fluids, antibiotics, rest, avoided going to the ER, cancelled travel plans.

One of my doctors asked a very simple question: is this happening more frequently? The answer, we both knew, was yes. But I don’t have a Personal Health Record (PHR) that in principle, through a few clicks, would give a time-frame graph of the bouts and severity of the episodes over the past several years.

The last time this happened, and the time before that, I thought I’d finally start a PHR. Like most compulsive patients, I keep records about my health. In the folder in my closet in a cheap old-fashioned filing box, the kind with a handled top that flips open, I’ve got an EKG from 15 years ago, an OR report from my spine surgery, copies of lab results that the ordering physicians chose to send me, path reports from my breasts, a skin lesion or two, and, more recently a colonic polyp, bone density studies from 2004, EMGs and more, essentially miscellaneous results.

None of the records I have are digital.

A few years back I considered using Google Health. But their service, as I understood it, involved scanning documents and uploading them to the Cloud, or paying someone else to do so. That sounded like a hassle. But even had I done that, I wouldn’t have been able to, say, see a graph of my hemoglobin since 1986, or something as simple as my weight changes over time. When Google Health folded a few months back, I was disappointed. At the same time, I breathed a sigh of relief that I hadn’t invested my personal and limited energies into putting my records there.

But I needed no convincing. What I need is software, or a platform, that’s user-friendly and secure. Ideally mine would mesh with my physicians’ records, but my doctors use a variety of record systems. So it’s up to me to integrate the data, if anyone will. The problem is there’s little out there, as best I can tell, that’s intended for patients. Most IT companies are, for now, focused on getting doctors to sign on.

So I’ll start an Excel spreadsheet, today, on my PC. There must be a better way.

A short note on Cutting for Stone, a novel I’ve just read by Dr. Abraham Verghese. He’s an expert clinician and professor at Stanford. The author uses rich language to detail aspects of Ethiopian history, medicine and quirks of human nature. The book’s a bit long but a page-turner, like some lives, taking a strange and sometimes unexpected course.

For today I thought I’d mention one passage that haunts me. It appears early on, when the protagonist, a man in middle age reflects on his life and why he became a physician:

My intent wasn’t to save the world as much as to heal myself. Few doctors will admit this, certainly not young ones, but subconsciously, in entering the profession, we must believe that ministering to others will heal our woundedness. And it can. But it can also deepen the wound.

The point is, a physician may be immersed in his work in a manner that he is, in effect, “addicted” to practicing medicine – a term Verghese uses later on in the book. There’s an emotional boost, or relief, some doctors glean by their daily tasks. An example he gives is a surgeon who feels better upon seeing his patient, who’d been sick, recovering nicely after an operation. This applies in other fields, including oncology.

I get this. It’s an under-discussed aspect of being a doctor, articulated well in some characters’ pathology and passion.

Yours truly, the author of Medical Lessons, is listening to music while she writes. A live version of the Stones’ “Silver Train” has just come on, and she’s happily reminded of something that happened 30 years ago. Distracting? Yes. Calming? Yes. Paradoxically helps to keep me on track? Yes.

My iPod keeps my mind from wandering further. And it lifts my mood.

And so here, on my blog, which is not peer-reviewed or anything like that, I put forth the medical concept of “iPod therapy.”

“When you’re weary, feeling small…” Music can help.

Today’s news reports that 1 in 5 Americans take drugs for psychiatric conditions. That sounds like a lot to me, but I’m no pharmaceutical surveyor. Of course many people need and benefit from medical help for depression and other mental illnesses.

But, in all seriousness, I wonder how many people might use music like a drug to keep them relaxed, happy, alert…

Why not prescribe music? It works for me, n=1.

Maybe doctors should be recommending iPods, or radios, or Pandora to some of their patients who are feeling down. I hope an academic psychiatrist somewhere, without ties to Apple or Pandora or Bose or other relevant party is coordinating a careful, prospective study of this promising and relatively inexpensive intervention.

As best I can tell, music is non-addictive. Except that if I had to live without it, I’d start humming, or maybe singing, which might be detrimental to those who live near.

A funny thing happened at my doctor’s appointment on Friday. I checked in, and after confirming that my address and insurance hadn’t changed since last year, waited for approximately 10 minutes. A worker of some sort, likely a med-tech, called me to “take my vitals.”

She took my blood pressure with a cuff that made my germ-phobic self run for self-regulation, i.e. I stayed quiet and didn’t express my concern about the fact that it looked like it hadn’t been washed in years. I value this doctor among others in my care, and I didn’t want to complain about anything. Then the woman took my weight. And then she asked if she could take my picture, “for the hospital record.”

I couldn’t contain my wondering self. “What is the purpose of the picture?” I asked.

“It’s for the record,” she explained. “For security.”

I thought about it. My picture is pretty much public domain at this point in my life, a decision I made upon deciding not to blog anonymously. Besides, most everyone at the medical center used to know me, including the receptionists, janitors, cafeteria cashiers, nurses’ aides, social workers, deans, full professors, geneticists, fellows in surgery and old-time voluntary physicians, among others who work there. So why didn’t I want this unidentified woman who works in my oncologist’s office to take my picture?

It made me uncomfortable, and here’s the reason: My picture is a reminder that, without it, I might be like any other patient in the system. They (administrators?, nurses, other docs, maybe even my future doctors) will need or want the picture to recall and be certain who Elaine Schattner is.

Don’t get me wrong. I agreed to the photo after all of maybe 20 seconds deliberating. (And my doctor was, I soon learned, duly informed I’d “had an issue” with it. Was that for just asking the reason?) The unidentified med-tech person used an oddly small, ordinary pink camera to complete her task.

When I met with my doctor, she explained that the photo is for security and, essentially, to reduce the likelihood of errors. The hospital has records of so many thousands of patients, many who have similar or identical names. There are good reasons to make sure that your notes on “Sally Smith” are entered into the chart of “Sally Smith” who is your patient.

It’s understandable. I remember when at the nurses’ station there’d be a sign (on “our” side) saying something like “CAREFUL: Anna Gonzalez in 202, Alma Gonzalez in 204b,” or something like that.

Patients blur.

It’s hard, veritably impossible, for most doctors and nurses to keep mental track of all of the patients they’ve ever seen and examined. There’s utility in the new system. Yes, it’s a good idea for a doctor, say upon receiving a call from a woman she hasn’t seen in 3 or 6 or 9 years, to see her picture in the chart, as a reminder.

But I hope my doctors know who I am, and not just what I look like in the image.

On Friday I visited the Scar Project exhibit at Openhouse, on Mulberry Street just south of Spring. Photographer David Jay offers penetrating, large, wall-mounted images of young people with breast cancer.

The photos reveal women who’ve have had surgery, radiation, reconstruction or partial reconstruction of the breasts. Some are strikingly beautiful. Some appear confused, others confident. Some look right at you, defiant or maybe proud. Some, post-mastectomy, adopt frankly or strangely sexual postures. Others hide a breast, or turn away from the lens.

This collection is not for everyone. The photos of ravaged bodies of women with cancer might be upsetting, if not frankly disturbing, to some who look at them. Not everyone chooses to do so.

The women’s scars and expressions are telling. Though not representative, these images reflect wounds not often-shown in medical journals, or elsewhere.

Few BC news items irk some women I know more than those linking alcohol consumption to the Disease. Joy-draining results like those reportedthisweek serve up a double-whammy of guilt: first – that you might have developed cancer because you drank a bit, or a lot, or however much defines more than you should have imbibed; and second – now that you’ve had BC, the results dictate, or suggest at least, it’s best not to drink alcohol.

The problem is this: If you’ve had BC and might enjoy a glass of wine, or a margarita or two at a party, or a glass of whiskey, straight, at a bar, or after work with colleagues, or when you’re alone with your cat, for example, you might end up feeling really bad about it – worse than if you had only to worry about the usual stuff like liver disease and brain damage, or if you could simply experience pleasure like others, as they choose.

The newly-published correlative data, in the Nov 2 issue of JAMA, are clear. The findings, an offshoot of the Nurses’ Health Study, involve over 105,000 women monitored from 1980 until 2008. The bottom line is that even low levels of alcohol consumption, the equivalent to 3-6 drinks per week, are associated with a statistically significant but slight increase in breast cancer incidence. And the more a woman drinks, the more likely she is to develop breast cancer.

All things considered, it might be true that alcohol is a breast carcinogen, as Dr. Steven Narod calls it in the editorial accompanying the research study. Still, there’s no proof of cause and effect: Other factors, like consuming lots of food or perhaps some yet-unidentified particularity about living in communities with abundant food and alcohol, are potential co-variables in this story. But what if it is true?

These findings raise an important clinical question: should postmenopausal women stop drinking to reduce their risk of breast cancer? For some women the increase in risk of breast cancer may be considered substantial enough that cessation would seem prudent. However, there are no data to provide assurance that giving up alcohol will reduce breast cancer risk.

How I see it is this: Everything’s best in moderation, including enjoyment of one’s life. You work, you rest, you have some fun.

This evidence is not like the strong data linking cigarettes to smoking that officials sat on for a few decades under the influence of the tobacco industry. This is a plausible, mild, and at this point well-documented correlation.

I don’t deny the sometimes harmful effects of alcohol; no sane physician or educated person could. But if you have a glass of wine, or even a second, so long as you don’t drive a car or work while affected, I don’t see it as anyone’s business but your own. More generally, I worry about how much judging there is by people who behave imperfectly, and how that can make individuals who are good people in most ways feel like they don’t deserve to be happy or enjoy their lives.

Women, in my experience, are generally more vulnerable to the put-downs of others. And so my concern about the BC-alcohol link is that this will, somehow, be used, or have the effect of, making survivors or thrivers or women who haven’t even had breast cancer feel like they’re doing the wrong thing if they go to a party and have a drink. And then they’ll feel badly about themselves.

Really I’m not sure what more to say on this loaded topic, except that it points to the deeper and broader ethical dilemma of doctors who are not all perfect examples of moderation, expecting and asking other people to change their personal habits when they themselves like to go out and have fun, and drink, at parties, or have wine in the evenings over dinner in the privacy of their homes.

How shall I resolve this post?

Last night I sipped Sleepytime tea, manufactured by Celestial Seasonings, before reading a book. The stuff is said to be 100% natural, with “a soothing blend of chamomile, spearmint and lemongrass.” I tried it first a few weeks ago and, by a placebo effect or through real chemistry, it helps me sleep more soundly.

I’ve absolutely no idea what are the effects of “Sleepytime tea” on breast cancer. It might help, it might hurt, or it might do nothing at all.

A curious diagram appeared in the most recent NEJM, in a perspective on U.S. dietary guidelines. It’s a USDA food wheel from the early 1940s. With Twitter-like style, it says: “For Health…eat some food from each group…every day!

The details are rich: “butter and fortified margarine” constitute 1of the 7 groups. Further inspection-worthy, IMO.

The Arizona Republic reports on a divided community in Gilbert, AZ. At issue is the high school cheerleading team’s plan to wear pink tee shirts with the slogan: “Feel for lumps – save your bumps” on the back. The group’s intention was to raise awareness and funds for the Susan G. Komen Foundation.

The school’s principal said no to the controversial outfits due to their “unacceptably suggestive” content.

What strikes me, among other interesting aspects of this story and what it reflects about BC awareness in 2011, is how the arguments (so needless!) about fundraising play out so differently, depending where you live and the newspapers you might read.

A few days ago I had a colonoscopy to evaluate some gastrointestinal problems. Subjective summary: Yuck. Downing 3 liters of Nu-Litely, a hyper-osmotic colonic cocktail prep, does not make for a pleasant Sunday afternoon, evening or night. As for the procedure itself, I don’t know how Katie Couric did it on TV.

But what made the procedure tolerable, and non-scary, and worthwhile, was that it was done by a careful, experienced gastroenterologist in a well-run facility. The outpatient unit where I had my colonoscopy employs reputable anesthesiologists and maintains functional, appropriate monitoring instruments and, should they be needed, life-saving equipment.

… after concluding that the standards were obsolete or overly burdensome to the industry.

Kathleen Sebelius, the secretary of health and human services, said the proposed changes, which would apply to more than 6,000 hospitals, would save providers nearly $1.1 billion a year without creating any “consequential risks for patients.”

A few aspects of the proposed regulatory pull-back seem reasonable, like allowing hospitals to delegate more work to nurse-practitioners. But some of this regulatory reversal sounds dangerous:

…Other proposals would eliminate requirements for hospitals to keep detailed logs of infection control problems…

…Federal officials would also eliminate a detailed list of emergency equipment that must be available in the operating rooms of outpatient surgery centers. Such clinics would have leeway to decide what equipment was needed for the procedures they performed.

Fortunately, the administration is accepting public comments on this matter for 60 days. But they could make it easier. Instructions from the HHS press release involve a series of links:

To view the proposed and final rules, please visit: www.ofr.gov/inspection.aspx…Both proposals invite the public, including doctors, hospitals, patient advocates, and other stakeholders, to comment. To submit a comment, visit www.regulations.gov, enter the ID number CMS-9070-P or CMS-3244-P, and click on “Submit a Comment.”

My position is that any lessening of infection control is a disservice to patients. As for monitoring of outpatient facilities where procedures are performed, it’s crucial; patients rely on maintenance of modern, clean and functional equipment in places where they receive medical care.

My bottom line: Patient safety should take precedence over cost-saving measures by the inspectors and the inspected.

It was a Wednesday afternoon. I was in clinic, caring for patients with blood diseases. In between seeing my patients and supervising the residents and fellows, I checked my voice mail. The message from Dr. L. said I should please contact her. Already, by the tone of her voice, I knew the results of the needle biopsy I’d had the morning before. It was positive. I had an infiltrating ductal carcinoma in the left breast.

I stayed to finish seeing the patients. Around 6PM, I went back to my office to complete notes and return calls. Only after all that was done, my desk set with a decipherable stack of tasks and charts – just in case someone else should need to complete my work, I went home.

In the city where I live, it’s hard to buy a muffin at a Starbucks without stepping back from the counter and reconsidering. Swallowing 460 calories for a minimal-nutrient breakfast seems foolish.

So I eat fewer muffins than I used to. The posted nutritional tidbits, however imprecise, on the contents of pieces of quiche, slices of pizza and cups of thick soup, stick with me when I travel, and at home.

Today I visited my internist for a checkup and flu shot. We talked about how I’m doing, and she examined me, and we discussed what procedures I ought have done and not done. She’s been my doctor since the summer of 1987, when I was an intern at the hospital.

We reviewed so much that has happened in the interim.

How rare it is, now, to have a doctor who knows me. Continuity in care is so valuable.

One of my greatest fears is being in the hospital again, and having hospitalists – doctors who work full-time in the hospital – be the ones to see me each day, and make decisions about what I need. Yet I’m bracing for it because, well, that’s how it is, now.

From a health care administration perspective, I recognize the value of delegating inpatient care to physicians who are not my usual doctors. And from the perspective of a physician who after hours and on weekends, would walk to and from the hospital, back and forth, countless times, to see my patients when they were sick, I know it’s neither cost-effective nor wise for physicians to push themselves to get over to the hospital before or after they’ve gone home, and called everyone back, and maybe eaten dinner. Doctors need rest, too.

But as a patient, when I’ve been in the hospital, nothing was more reassuring than visits by my usual doctors – my internist, my oncologist, my surgeon, my orthopedist…Being cared for by strangers, however competent, is not the same, although there may never be a study to prove it.

The Caregiver’s Dilemma considers the 61.6 million people in the U.S. who care for older relatives or friends. People with jobs are, understandably, unsure if they should let their boss or supervisor know they’re caring for someone who’s sick. This indirect cost of illness and aging in America is said to tally $33.6 billion each year.

Many employees are in that elder care-giving boat, yet workers with work-family conflicts are often reluctant to raise the issue with superiors. They fear they’ll be viewed as not committed enough, or receive bad year-end reviews. They may also think that discussing their personal life is unprofessional or sense resentment from colleagues and the boss, who may have to pick up the slack during their absences…

The article reminded me of the dilemma faced by cancer patients, and by the parents or children of anyone who’s got a serious diagnosis and needs help. How much to tell the boss?

Yesterday morning I wrote a short post on CelebrityDiagnosis.com. By evening, news broke that Apple founder and CEO Steve Jobs resigned from his position, presumably for reasons of his health.

What’s public, by Jobs’ decision, is that he had a relatively good, typically slow-growing kind of malignancy in the pancreas, a neuroendocrine islet cell tumor. He informed Apple employees by email about his diagnosis in 2004, when he was 49 years old. Since then he’s had a liver transplant. Possible complications of that surgery, or the tumor itself, have led to considerable speculation. But little is known about the details of why he took medical leave in January and is stepping down now.

In a published letter to the Apple Board and Community, he wrote yesterday: “I have always said if there ever came a day when I could no longer meet my duties and expectations as Apple’s C.E.O., I would be the first to let you know. Unfortunately, that day has come.”

The letter was “short and classy,” in David Pogue’s words, and I agree. I respect Jobs’ decision to keep the details of his medical condition private. That’s the thing – and where this is post is heading.

When public figures are open about their illnesses, it can be helpful, instructive and even necessary. For example, if a political figure, say Fidel Castro or Hugo Chavez or Dick Cheney, with considerable power develops a cancer or has a stroke or a heart attack or some other serious medical problem, the citizens have the right to know that the condition of the person they rely on has changed.

The problem is that in our culture there’s so much openness about medical conditions, individuals may feel compelled to tell what’s happening if they have cancer or a recurrence or some other unfortunate medical event. But not everyone wants to do so, nor should they feel obliged.